Public Health Emergencies: Data Management Challenges Impact National Response

Public health emergencies evolve quickly, but public health entities lack the ability to share new data and potentially life-saving information in real-time—undermining the nation's ability to respond quickly.

To address this, the federal government must overcome three major challenges—specifically, the lack of:

- Common standards for collecting data (e.g., patient characteristics)
- "Interoperability" (meaning not all data systems work together)
- Public health IT infrastructure (the hardware, software, networks, and policies that would enable the reporting and sharing of data)

This snapshot discusses our related work and recommendations.

Public health emergencies evolve quickly, but public health entities lack the ability to share new data and potentially life-saving information in near real-time. To address this, the federal government must overcome 3 major challenges in how it manages public health data. GAO has made a number of recommendations to help address these challenges. However, many of these recommendations have not been implemented.
The Big Picture

Longstanding challenges in the federal government’s management of public health data undermine the nation’s ability to quickly respond to public health emergencies like COVID-19 and monkeypox. These challenges include the lack of:

- common data standards—requirements for public health entitles to collect certain data elements, such as patient characteristics (e.g., name, sex, and race) and clinical information (e.g., diagnosis and test results) in a specific way;
- interoperability—the ability of data collection systems to exchange information with and process information from other systems; and
- public health IT infrastructure—the computer software, hardware, networks, and policies that enable public health entities to report and retrieve data and information.

Over 15 years ago, federal law mandated that the Department of Health and Human Services (HHS) establish a national public health situational awareness network with a standardized data format. This network was intended to provide secure, near real-time information to facilitate early detection of and rapid response to infectious diseases.

However, the federal government still lacks this needed network and has not yet overcome the challenges identified in previous GAO reviews. Having near real-time access to these data could significantly improve our nation’s preparedness for public health emergencies and potentially save lives.

Without the network, federal, state, and local health departments, hospitals, and laboratories are left without the ability to easily share health information in real-time to respond effectively to diseases.

GAO’s prior work identified three broad challenges to public health data management and recommended actions for improvement.

1. Common Data Standards

To ensure that information can be consistently reported, compared, and analyzed across jurisdictions, public health entities need a standardized data format. Due to the lack of common data standards, information reported by states about COVID-19 case counts was inconsistent. This in turn complicated the ability of the Centers for Disease Control and Prevention (CDC) to make comparisons. Public health representatives also noted challenges in collecting complete demographic data. This made it difficult to identify trends in COVID-19 vaccinations and the number of doses administered. Although CDC had intended to implement data standards, its strategic plan did not articulate specific actions, roles, responsibilities, and time frames for doing so.

- Re recommended that HHS establish an expert committee for data collection and reporting standards by engaging with stakeholders (e.g., health care professionals from public and private sectors). This committee should review and inform the alignment of ongoing data collection and reporting standards related to key health indicators.
- Recommended that CDC define specific action steps and time frames for its data modernization efforts.

2. Interoperability among Public Health IT Systems

The inability to easily exchange information across data collection and other data systems creates barriers to data sharing and additional burdens on entities that collect and transmit data. During the early stages of COVID-19, the lack of IT system interoperability caused health officials and their key stakeholders (e.g., hospitals) to manually input data into multiple systems. In addition, some state health departments could not directly exchange information with CDC via an IT system. This led to longer time frames for CDC to receive the data they needed to make decisions on the COVID-19 response.

- Recommended that, as part of planning for the public health situational awareness network, HHS should ensure the plan includes how standards for interoperability will be used.

3. Lack of a Public Health IT Infrastructure

The timeliness and completeness of information that is shared during public health emergencies can be impeded by the absence of a public health IT infrastructure. During the early stages of COVID-19, some states had to manually collect, process, and transfer data from one place to another. For example, a state official described having to fax documents, make copies, and physically transport relevant documents. The official noted by establishing a public health IT infrastructure, such as the network HHS was mandated to create, errors would be reduced. To help mitigate challenges in data management for COVID-19, HHS launched the HHS Protect platform in April 2020. However, we reported that public health and state organizations raised questions about the completeness and accuracy of some of the data.

- Recommended that HHS prioritize the development of the network by, in part, establishing specific near-term and long-term actions that can be completed to show progress.
- Recommended that HHS identify an office to oversee the development of the network.
- Recommended that HHS identify and document information-sharing challenges and lessons learned from the COVID-19 pandemic.

French hospital forced to transfer patients following Ransomware attack

The Centre Hospitalier Sud Francilien (CHSF) said an attack on its computer network was detected in August. The hospital has referred patients elsewhere as the cyberattack rendered various technical systems ‘inaccessible’.

The cyberattack made various systems “inaccessible” including business software, storage systems in areas such as medical imaging, and the info systems on patient admissions, according to a CHSF statement.

As a result of the attack, patients whose care requires access to the hospital’s technical systems have been redirected to other hospitals in the area. Those who present themselves to the emergency room are being evaluated by CHSF’s medical staff, and being transferred to other institutions if necessary.

The hospital, which serves an area of around 600,000 people, said that measures have been taken to care for those already hospitalised there. However, the “exceptional situation” is expected to have an impact on the operating room, as it is closely linked to the affected technical platform.

French paper Le Monde reports that a ransom of $10m was demanded by the hackers responsible.

CISA, FBI and Treasury Release Advisory on North Korean State-Sponsored Cyber Actors Use of Maui Ransomware

Healthcare and Other Sectors Provided with Proactive Steps to Detect and Reduce Risk

The Cybersecurity and Infrastructure Security Agency (CISA), the Federal Bureau of Investigation (FBI), and the U.S. Department of the Treasury (Treasury) today released a joint Cybersecurity Advisory (CSA) that provides information on Maui ransomware, which has been used by North Korean state-sponsored cyber actors since at least May 2021 to target Healthcare and Public Health (HPH) Sector organizations.

The CSA titled, “North Korean State-Sponsored Cyber Actors Use Maui Ransomware to Target the Healthcare and Public Health Sector,” provides technical details and indicators of compromise (IOC) observed during multiple FBI incident response activities over a period of more than a year and obtained from industry analysis of Maui samples. North Korean state-sponsored actors were observed using Maui ransomware to encrypt HPH servers responsible for providing healthcare services. In some cases, the malicious activity disrupted the services provided by the victim for prolonged periods.

“As the nation’s cyber defense agency, our team works tirelessly in collaboration with partners to publish timely information that can help organizations prevent and build resilience against all cyber threats,” said CISA's Executive Assistant Director for Cybersecurity, Eric Goldstein. “Today’s advisory comes out of our strong partnership with the FBI and Treasury. This malicious activity by North Korean state-sponsored cyber actors against the healthcare and public health sector poses a significant risk to organizations of all sizes.”

"The FBI, along with our federal partners, remains vigilant in the fight against North Korea's malicious cyber threats to our healthcare sector," said FBI Cyber Division Assistant Director Bryan Vorndran. "We are committed to sharing information and mitigation tactics with our private sector partners to assist them in shoring up their defenses and protecting their systems."

“Ransomware victimizes people and businesses, large and small, across America. Treasury has worked closely with CISA and FBI to counter ransomware and protect financial sector critical infrastructure,” said Rahul Prabhakar, Treasury Deputy Assistant Secretary for Cybersecurity and Critical Infrastructure Protection. “This joint advisory on Maui ransomware provides guidance that organizations of all sizes across the country can use to help defend themselves. We will continue to work closely with our partners to push out actionable information on ransomware and other malicious activity as quickly as possible to help individuals and businesses guard against ever-evolving cyber threats.”

The HPH Sector, as well as other critical infrastructure organizations, are urged to review this joint CSA and apply the recommended mitigations to reduce the likelihood of compromise from ransomware operations. The FBI, CISA, and Treasury assess that North Korean state-sponsored actors are likely to continue targeting HPH Sector organizations, because of the assumption that these organizations are willing to pay ransoms to avoid disruption of the critical life and health services they provide. For more information on state-sponsored North Korean malicious cyber activity, see CISA’s North Korea Cyber Threat Overview and Advisories webpage.

The FBI, CISA, and Treasury strongly discourage paying ransoms as doing so does not guarantee files and records will be recovered and may pose sanctions risks. In September 2021, Treasury issued an advisory highlighting the sanctions risk associated with ransomware payments and providing steps that can be taken by companies to mitigate the risk of being a victim of ransomware.

The satellite-enabled emergency response system that could make a life-saving difference

The COVID-19 pandemic has challenged ambulance services like never before. First RESPonse was created to help professionals respond to emergency calls more rapidly through enhanced technology. With support by ESA Space Solutions, the system developed in a Demonstration Project streamlined communication and information sharing throughout the chain of response and reduced call-to-hospital times for patients by up to 17%.

During the worst months of the COVID-19 pandemic, emergency call centres experienced extremely high rates of urgent medical calls. Coordination of the ambulance response was challenging and made more complex by the changing landscape of medical resources; hospitals were filling up, and temporary emergency facilities were opening.

The First RESPonse (First Rapid Emergency System against Pandemic) project launched in Italy in July 2020, with the aim to improve coordination of the entire process of a medical emergency request: from a patient’s distress call to the point of hospitalisation.

The project brought together two major players in European emergency service software and telecommunications: GINA Software and Beta 80. Forming a new consortium, the companies achieved complete integration of their products and – supported by ESA – incorporated space technology for enhanced geolocation accuracy and communication coverage.
Digital links for a faster chain

First RESPonse digitally connects each link in the emergency chain of response. It begins with an app on a citizen’s smartphone, through which they can call for help, see when help has been dispatched and when it is due to arrive. Ambulance dispatchers in the call centre have a constant digital connection to their crews via a workstation. They can keep them updated on the scene and patient’s condition, and the status of the nearest hospital facilities. First responders have a tablet through which they receive up-to-date information about the patient, automatic SatNav to their location and can video consult with a doctor from the field. They can also scan the patient’s ID card so that receiving hospitals know who is coming in, as well as seeing when they are expected.

The system was piloted by selected ambulance services in Italy and the Czech Republic and used in almost 9,000 incidents. In this pilot project, First RESPonse accelerated the pre-hospital chain by between 12 and 17%.

Arnaud Runge, Medical Engineer at ESA said: “In a medical emergency every minute counts. Cutting the time it takes an ambulance to reach a critically ill patient, and to get them to hospital, can make a life-saving difference. We’re proud to have enhanced First RESPonse with space technology.”
From pandemic to systemic

Following the successful completion of the pilot, First RESPonse is being promoted to emergency services more widely in Italy and the Czech Republic – where GINA and Beta 80 have most of their customers – and beyond.

Martin Ingr from GINA said: “The products and services that were created during the project are aimed to remain sustainable also after the pandemic is overcome. Our goal is that the problems solved through the First RESPonse project become part of the standard operation procedure. The system can be used again against this or other pandemics, during the response to disasters such as earthquakes, as well as improving daily operations of emergency services.”

[Source: ESA]

Testing the Resilience of the European Healthcare Sector

To ensure citizens’ trust in the medical services and infrastructure available to them, health services should function at all times. If health services and infrastructures in Europe were the object of a major cyber attack, how would we respond and coordinate at both national and EU level to mitigate the incidents and prevent an escalation?

This is the question Cyber Europe 2022 sought to answer using a fictitious scenario. Day one featured a disinformation campaign of manipulated laboratory results and a cyber attack targeting European hospital networks. On day two, the scenario escalated into an EU-wide cyber crisis with the imminent threat of personal medical data being released and another campaign designed to discredit a medical implantable device with a claim on vulnerability.

The Executive Director of the EU Agency for Cybersecurity, Juhan Lepassaar, said: “The complexity of our challenges is now proportionate to the complexity of our connected world. This is why I strongly believe we need to gather all the intelligence we have in the EU to share our expertise and knowledge. Strengthening our cybersecurity resilience is the only way forward if we want to protect our health services and infrastructures and ultimately the health of all EU citizens.”

The pan-European exercise organised by ENISA rallied a total of 29 countries from both the European Union and the European Free Trade Association (EFTA), as well as the EU agencies and institutions, including ENISA, the European Commission, the CERT of EU Institutions, bodies and agencies (CERT-EU), Europol and the European Medicine Agency (EMA). More than 800 cybersecurity experts were in action to monitor the availability and integrity of the systems over the two days of this latest edition of Cyber Europe.

Can we strengthen the cyber resilience of the EU healthcare?

The participants who engaged in the complex exercise were satisfied with the way the incidents were dealt with and the response to fictitious attacks.

Now, the analysis of the process and of the outcomes of the different aspects of the exercises need to be performed in order to get a realistic understanding of potential gaps or weaknesses which may require mitigation measures. Dealing with such attacks requires different levels of competences and processes which include efficient and coordinated information exchange, the sharing of knowledge around specific incidents and how to monitor a situation which is about to escalate in case of a generalised attack. The role of the EU level CSIRTs network and the draft standard operation processes (SOPs) of the CyCLONe group also need to be looked into.

The deeper analysis will be published in the after-action report. The findings will serve as a basis for future guidance and further enhancements to reinforce the resilience of the healthcare sector against cyber attacks in the EU.

GAO Cybersecurity Report and Recommendations for HHS

The Government Accountability Office (GAO) wants HHS to improve cybersecurity efforts by strengthening collaboration within the department and with the broader healthcare sector.
Health care organizations' IT systems are critical to the nation's well-being. Cyberattacks on them could, for example, put patient privacy at risk or disrupt essential telehealth services. (The nation's cybersecurity is on our High Risk List.)
The Department of Health and Human Services coordinates with health care organizations and others to support cybersecurity efforts. Its policies and procedures clearly describe roles and responsibilities, which is good for collaboration.
GAO is making seven recommendations to HHS to improve its collaboration and coordination within the department and the sector:
1. The HHS secretary should have the CIO overseeing the coordination and sharing of cybersecurity information between the Health Sector Cybersecurity Coordination Center and Healthcare Threat Operations Center.
2. The HHS secretary should order the CIO to monitor, evaluate and report on the progress and performance of the HHS Chief Information Security Officer Council, Continuous Monitoring and Risk Scoring Working Group, and Cloud Security Working Group.
3. HHS should direct the assistant secretary for preparedness and response to monitor, evaluate and report on the progress and performance of the Government Coordinating Council's Cybersecurity Working Group and HHS Cybersecurity Working Group.
4. HHS should have the CIO regularly monitor and update written agreements that describe how the HHS Chief Information Security Officer Council, Continuous Monitoring and Risk Scoring Working Group, and Cloud Security Working Group will collaborate and ensure that officials review and approve the updated agreements.
5. HHS should direct the assistant secretary for preparedness and response to ensure that authorizing officials review and approve the charter describing how the HHS Cybersecurity Working Group will manage collaboration.
6. HHS should have the assistant secretary for preparedness and response do the following: finalize written agreements that include a description of how the Government Coordinating Council's Cybersecurity Working Group will work together; identify the working group's roles and responsibilities; monitor and update the written agreements on a regular basis; and ensure that authorizing officials leading the working group approve the final agreements.
7. HHS should tell the assistant secretary for preparedness and response to update the charter for the Joint Healthcare and Public Health Cybersecurity Working Group for the current fiscal year and ensure that authorizing officials overseeing the group review and approve the updated charter.

IAEA and FAO Help Burkina Faso and Algeria to Enhance Food Safety & Security

The IAEA and the Food and Agriculture Organization of the United Nations (FAO) cooperate in supporting food safety and food quality programmes around the world to address food hazards, food fraud and advise countries on food irradiation. Among the beneficiaries of this programme have been Burkina Faso and Algeria. To celebrate World Food Safety Day, we are drawing attention to the importance of nuclear techniques in monitoring food safety. “Safe food today for a healthy tomorrow” – this year’s theme – recognizes how safe food contributes to a healthy life, economy, planet and future.
Enhanced food safety capabilities in Burkina Faso
Tiny but oil- and vitamin-rich sesame seeds have become a staple of Burkina Faso’s economy – creating jobs and generating income. After cotton, the edible seeds that grow in pods have become the West African country’s second most exported agricultural product. This sprouting success in the last decade has been sustained with the help of Burkina Faso’s National Public Health Laboratory (LNSP), supported by the IAEA and FAO, through their Joint Cenre on Nuclear Techniques in Food and Agriculture.
Enhancing food safety analytical capabilities in Algeria
Laboratories in Algeria have received the support to enhance their analytical capabilities for the detection of chemical hazards, including antimicrobial and pesticide residues in a range of food, from poultry and eggs to dates and honey. Algeria was the world’s sixth leading exporter of dates, worth approximately US $129 million in 2020.
Through the IAEA’s technical cooperation programme and in partnership with FAO, staff of the Algerian National Institute for Agronomic Research (INRAA) and the National Institute of Veterinary Medicine (INMV) have been trained in methods of analysis and supported with the required analytical equipment. These institutions are now equipped to contribute towards consumer protection and the trade of agricultural products.

Recommendations for measures to prevent hospital fires

The European Commission’s Joint Research Centre (JRC) issued a series of recommendations to help prevent the hospital fires associated with medical oxygen needed for Covid-19 severely ill patients, from electrical maintenance to administrative measures and largely spread training and guidance on prevention and risk management strategies for oxygen hazards.

Since the outbreak of the pandemic in March 2020, at least 36 incidents of hospital fires associated with intense oxygen use have been found to have occurred in various countries around the world, causing the deaths of over 200 people and injuring many more.

The majority of the dead and injured were patients extremely ill with the novel Coronavirus and others were their health care providers. Most deaths resulted directly from the fire but there were also several deaths from patients deprived of oxygen because of the event.

In comparison, up until 2020, the media shows an average of just over one such event per year since 2011.

According to the JRC recommendations, the strategies to prevent and mitigate the fire risk in intensive care units should evolve around three main elements:

• Guidance on oxygen therapy for Covid-19 and other diseases needs to identify specific prevention measures that can reduce the risk of oxygen-enriched environments in these settings;

• All hospitals should establish a risk management strategy for oxygen hazards led by hospital management, involving all staff, including healthcare workers, maintenance, housekeeping and administration;

• As part of this policy, all hospitals should track the number of patients having medical gas treatment and, when elevated, an appropriate fire risk management policy should be applied.

The hospitals should use as examples strategies developed for chemical process safety to manage flammable and explosive atmospheres. The management procedures should involve medical and non-medical staff, and prevention and emergency preparedness should take into account potential intensive care unit fires.

Guidelines for Cybersecurity in Hospitals: New Online tool

The new tool helps healthcare organisations identify best practices in order to meet cybersecurity needs when procuring products or services.
To facilitate the use of the Procurement Guidelines for Cybersecurity in Hospitals published in 2020, ENISA releases an online tool today to support the healthcare sector in identifying procurement good practices to meet cybersecurity objectives when procuring products or services.
In addition, the Agency also publishes a concise version of the procurement guidelines dedicated to the sector in each of the 24 EU official languages.
Cybersecurity in Healthcare: why does it matter?
The COVID-19 pandemic demonstrated the value of eHealth services such as telemedicine and remote patient care.
Since it has become increasingly digital and interconnected, the healthcare sector needs to consider cybersecurity as an enabler and as a key factor for ensuring the resilience and availability of key healthcare services.
Cybersecurity needs to be envisaged throughout the procurement lifecycle. IT departments should be involved in procurement activities as the cybersecurity implications in the procurement of any product or service should be well understood and consistently addressed by healthcare organisations.
EU Agency for Cybersecurity Executive Director, Juhan Lepassaar, declared: “Securing eHealth today means ensuring the resilience of the EU’s life support system, the healthcare sector. ENISA is committed to shape the ICT environment needed to prevent cybersecurity incidents and attacks on our healthcare sector.”
Procurement Guidelines and online tool: What for?
The online tool was developed as a complement to the procurement guidelines for cybersecurity in hospitals. Its purpose is:
- To help healthcare organisations to quickly identify the guidelines that are most relevant to their procurement context such as assets procured or related threats;
- To promote the importance of a good procurement process to ensure appropriate security measures.
To facilitate the dissemination of good practices across all healthcare organisations across the EU, a concise version of the procurement guidelines is now made available in the 22 official EU languages and the full version is available in english and spanish languages.
The report on procurement guidelines has already generated a significant interest in the healthcare cybersecurity community.
Stakeholders in the sector, including members of the eHealth Security Experts Group suggested the idea of an interactive format of the guidelines making it possible to customise searches and help decision making through informed procurement.
The guidelines were translated in order to allow health organisations across Member States to directly access the content in their own language.
Who is it meant for?
- Procurement officers of healthcare organisations;
- Healthcare professionals with technical positions or in charge of IT systems and equipment;
- Chief level executives such as CIO, CISO, CTO;
- The EU citizens involved in or seeking to develop knowledge and awareness on such processes.

Universal Health Services lost $67m to ransomware attack

UHS was among the first hit with the coordinated ransomware wave that targeted the healthcare sector last year. On September 29 last year, Universal Health Services announced in a press release that due to an IT security incident that took place two days earlier, it had to suspend user access to its IT applications related to operations located in the United States.
In the early hours of September 27, UHS clinicians and staff members took to Reddit to determine if other UHS employees across the country were experiencing similar computer and phone outages.
The thread detailed internet and data center outages, with one employee attributing the incident to a ransomware attack after seeing ransom messages from the Ryuk hacking group displayed on some computer screens.
Upon discovery, the IT team took all systems offline to prevent further propagation. The following day, UHS officials confirmed the event as an IT disruption, before reporting as a malware infection several days later.
The disruption caused by the ransomware attack was immense, considering UHS is among the largest providers of hospital and healthcare services in the US, featuring among Fortune 500 companies in 2019 with annual revenue of $11.4 billion and also ranking #330 in Forbes list of U.S.' Largest Public Companies.
The company employs around 90,000 people across 26 acute care hospitals, 330 behavioral health facilities, 41 outpatient facilities, and a number of ambulatory care access points and a network of physicians. Aside from the US, Universal Health Services also operates in Puerto Rico and the United Kingdom.
UHS said that it immediately implemented extensive IT security protocols and was working with security partners to restore the affected IT services as soon as possible. The incident caused temporary disruption to some clinical and financial operations, forcing acute care and behavioural health facilities to rely on offline documentation efforts to deliver round-the-clock patient care.
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